Management of autonomic dysreflexia associated with Charcot spinal arthropathy in a patient with complete spinal cord injury: Case report and review of the literature.

BACKGROUND: Charcot spinal arthropathy (CSA) clearly represents a challenge in long-term spinal cord injury patients, one that can have extremely uncomfortable and potentially lethal outcomes if not managed properly. CASE DESCRIPTION: A 66-year-old man with a history of complete C7 quadriplegia presented with new-onset autonomic dysreflexia that resulted from Charcot spinal arthropathy (CSA). Pathologic instability, in the atypical site of the mid-thoracic spine, spanning from the T8-T9 vertebral levels was appreciated on physical exam as an audible, palpable, and visible dynamic kyphosis; kyphosis was later confirmed on neuroimaging. Based on the CSA severity and sequelae, the patient underwent bilateral decompression laminectomy with lateral extracavitary arthrodesis and posterior instrumentation. Symptoms dramatically improved and at 1-year follow-up, dynamic thoracic kyphosis and most symptoms of autonomic dysreflexia had resolved. CONCLUSIONS: Based on our case and published reports, vigilant imaging and thorough physical examination in long-standing spinal cord injury could help early diagnosis and treatment of CSA, theoretically preventing development of cord atrophy and subsequent long-term sequelae. Surgical correction rather than bracing may be recommended in patients who have complete injury at or above T6 in patients with symptoms of autonomic dysreflexia associated with CSA confirmed on neuroimaging.

Best Practices for Outpatient Anterior Cervical Surgery: Results From a Delphi Panel.

STUDY DESIGN: Delphi Panel expert panel consensus and narrative literature review. OBJECTIVE: To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)). SUMMARY OF BACKGROUND DATA: Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings are lacking. METHODS: A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Predetermined consensus was set at 70% for each best-practice statement. RESULTS: A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and subcategories) achieved consensus, including preoperative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6). CONCLUSION: This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment. LEVEL OF EVIDENCE: 4.

Lumbar ligamentum flavum: spatial relationships to surrounding anatomical structures and technical description of en bloc resection.

BACKGROUND: One structure, the ligamentum flavum, nearly always encountered in lumbar spinal operations, has not been examined as an important anatomical landmark. In this context, we describe its relevance in corridors of small surgical exposures created by minimally invasive spinal approaches. MATERIAL AND METHODS: In cadaveric and intraoperative dissections, we introduce a systematic technique for resection of this ligament and clarify its anatomical relationships with the exiting nerve roots, pedicles, facet capsule, and midline epidural fat. Fixed human cadaveric spines were harvested en bloc to maintain the lower thoracic to sacral segments. A single coronal cut through the anterior portion of the pedicles ensured that the dorsal elements were intact. Viewed from the operative microscope, photographs depict the ligamentum flavum at various intraoperative steps. RESULTS: The ligamentum flavum can undergo safe en bloc sequential resection that widely exposes the disc space for discectomy and interbody fusion. Its superolateral and inferolateral attachments are identifiable landmarks, effective in locating the exiting nerve roots. Corners of the L4-L5 ligamentum flavum mark the axillae of the exiting nerve roots (i.e., its superolateral corner marks the axilla of the L4 nerve roots, and its inferolateral corner marks the shoulder of the L5 nerve roots). CONCLUSION: Our cadaveric and microscopic surgical dissections show the ligamentum flavum as seen in the new corridors of small surgical exposures during minimally invasive surgeries of the lumbar spine. Identifying this landmark, surgeons can envision the location of the nerve roots to help prevent their injury.

Conus medullaris syndrome after epidural steroid injection: Case report.

BACKGROUND: Given the risk of paralysis associated with cervical transforaminal injection, is it time to reconsider transforaminal injections of the lumbar spine? Arguments for discontinuing lumbar injections have been discussed in the anesthesia literature, raising concern about the risks of epidural steroid injections (ESIs). METHODS: In a 47-year-old man, paraplegia of the lower extremities developed, specifically conus medullaris syndrome, after he underwent an ESI for recurrent pain. Correct needle placement was verified with epidurography. Immediately after the injection, the patient felt his legs "going dead"; paraplegia of the lower extremities was noted. RESULTS: An initial magnetic resonance imaging study performed after the patient was transferred to the emergency department was unremarkable. However, a later neurosurgical evaluation showed conus medullaris syndrome, and a second magnetic resonance imaging study showed the conus infarct. We conducted a search of the PubMed database of articles from 2002 to 2011 containing the following keywords: complications, lumbar epidural steroid injection(s), cauda equina syndrome, conus medullaris infarction, spinal cord infarction, spinal cord injury, paralysis, paresis, plegia, paresthesia, and anesthesia. CONCLUSIONS: Summarizing this case and 5 similar cases, we weigh the potential benefits and risks of ESI. Although one can safely assume that this severe, devastating complication is rare, we speculate that its true incidence remains unknown, possibly because of medicolegal implications. We believe that the rarity of this complication should not preclude the continued use of transforaminal ESI; rather, it should be emphasized for discussion with patients during the consent process.

Presacral retroperitoneal approach to axial lumbar interbody fusion: a new, minimally invasive technique at L5-S1: Clinical outcomes, complications, and fusion rates in 50 patients at 1-year follow-up.

BACKGROUND: The presacral retroperitoneal approach to an axial lumbar interbody fusion (ALIF) is a percutaneous, minimally invasive technique for interbody fusion at L5-S1 that has not been extensively studied, particularly with respect to long-term outcomes. OBJECTIVE: The authors describe clinical and radiographic outcomes at 1-year follow-up for 50 consecutive patients who underwent the presacral ALIF. METHODS: Our patients included 24 males and 26 females who underwent the presacral ALIF procedure for interbody fusion at L5-S1. Indications included mechanical back pain and radiculopathy. Thirty-seven patients had disc degeneration at L5-S1, 7 had previously undergone a discectomy, and 6 had spondylolisthesis. A 2-level L4-S1 fusion was performed with a transforaminal lumbar interbody fusion at L4-5 in 15 patients. AxiaLIF was performed as a stand-alone procedure in 5 patients and supplemented with pedicle screws in 45 patients. Pre- and postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were evaluated and complications were tracked. Fusion was evaluated by an independent neuro-radiologist. RESULTS: At 1-year follow-up, VAS and ODI scores had significantly improved by 49% and 50%, respectively, versus preoperative scores. By high-resolution computer tomography (CT) scans, fusion was achieved in 44 (88%) patients, developing bone occurred in 5 (10%), and 1 (2%) patient had pseudoarthrosis. One patient suffered a major operative complication-a bowel perforation with a pre-sacral abscess that resolved with treatment. CONCLUSION: Our initial 50 patients who underwent presacral ALIF showed clinical improvement and fusion rates comparable with other interbody fusion techniques; its safety was reflected by low complication rates. Its efficacy in future patients will continue to be monitored, and will be reported in a 2-year follow-up study of fusion.

Vertebral osteomyelitis.

Vertebral osteomyelitis (VO) is an infectious disease of the vertebral body that requires early diagnosis with identification of the infecting organism to direct antibiotic therapy. Most VO can be treated nonsurgically, but 10% to 20% of cases require open surgical treatment. Excellent clinical outcomes can be achieved with appropriate medical and surgical treatment.

Video-assisted thoracoscopic dissection of the brachial plexus: cadaveric study and illustrative case.

OBJECTIVE: Standard surgical approaches to the brachial plexus require an open operative technique with extensive soft tissue dissection. A transthoracic endoscopic approach using video-assisted thoracoscopic surgery (VATS) was studied as an alternative direct operative corridor to the proximal inferior brachial plexus. METHODS: VATS was used in cadaveric dissections to study the anatomic details of the brachial plexus at the thoracic apex. After placement of standard thoracoscopic ports, the thoracic apex was systematically dissected. The limitations of the VATS approach were defined before and after removal of the first rib. The technique was applied in a 22-year-old man with neurofibromatosis who presented with a large neurofibroma of the left T1 nerve root. RESULTS: The cadaveric study demonstrated that VATS allowed for a direct cephalad approach to the inferior brachial plexus. The C8 and T1 nerve roots as well as the lower trunk of the brachial plexus were safely identified and dissected. Removal of the first rib provided exposure of the entire lower trunk and proximal divisions. After the fundamental steps to the dissection were identified, the patient underwent a successful gross total resection of a left T1 neurofibroma with VATS. CONCLUSION: VATS provided an alternative surgical corridor to the proximal inferior brachial plexus and obviated the need for the extensive soft tissue dissection associated with the anterior supraclavicular and posterior subscapular approaches.

Novel use of a threadwire saw for high sacral amputation. Technical note and description of operative technique.

The authors describe and demonstrate an innovative modification of the osteotomy procedure required to achieve a supraforaminal high sacral amputation in a patient harboring a large sacral chordoma. Via a combined anterior-posterior approach, three carefully placed threadwire saws were used to create releasing osteotomies through specific portions of the dorsal iliac crests and through the axial midportion of the S-1 vertebral body. The threadwire saws are pulled away from neurovascular and visceral structures, ensuring greater protection. Other advantages include markedly reduced blood loss while performing the osteotomies, a high degree of cutting accuracy, negligible bone loss, and ease and speed of bone cutting.

Adaptation of a standard low-field (0.3-T) system to the operating room: focus on pituitary adenomas.

iMRI is a reliable and safe tool to monitor the extent of resection and to avoid complications in the transsphenoidal surgical approach for pituitary tumors. The best indication for its application in transsphenoidal surgery is for patients with pituitary macroadenomas with suprasellar extension. The low-field 0.3-T magnet has a diagnostic imaging quality that provides surgeons with good intraoperative detail of the anatomic relations in the sellar region. In our experience, iMRI provided a distinct benefit in planned STR for invasive macroadenomas that compress the optic chiasm and in planned GTR for noninvasive tumors. The iMRI design adopted at our center includes important features, such as the use of ferromagnetic surgical instruments, elimination of patient transportation, and capability as a shared resource, that allow multipurpose diagnostic use and increased cost-effectiveness.

Intramedullary and extramedullary solitary fibrous tumor of the cervical spine. Case report and review of the literature.

Solitary fibrous tumor is a spindle cell tumor deriving from mesenchymal cells that arises most commonly in the pleura. Only very recently has this tumor been reported in the spine. A solitary fibrous tumor strongly resembles other spindle cell neoplasms of the spine and may be an unrecognized entity if not routinely considered in the differential diagnosis of spinal neoplasms. The authors report an unusual intra- and extramedullary location for a solitary fibrous tumor of the cervical spine. Findings in this case and a comprehensive review of the literature indicate that solitary fibrous tumors can originate from various spinal anatomical substrates and mimic both intra- and extramedullary tumor types.

Antitumor effect of secreted Flt3-ligand can act at distant tumor sites in a murine model of head and neck cancer.

The Flt3 ligand (Flt3-L) manifests antitumor activity, presumably due to its capacity to recruit dendritic cells and cause their proliferation. To assess whether local production of Flt3-L can mediate a "distant bystander" effect, murine B4B8 squamous cell carcinoma cells were transfected with a plasmid encoding a secretory form of Flt3-L to produce B4B8FL cells. Similarly, B4B8FL and B4B8 cells were transfected with herpes simplex virus thymidine kinase (HSVTK) to produce B4B8TK and B4B8FL/TK cells, which should be sensitive to ganciclovir (GCV), to know whether the effects of Flt3-L and HSVTK/GCV would be synergistic. To test for a distant bystander effect in vivo, B4B8FL, B4B8TK, and B4B8FL/TK cells were injected subcutaneously into the left flank of syngeneic Balb/c mice, and naïve B4B8 cells were injected into the right flank. The formation of tumors derived from B4B8FL and B4B8FL/TK cells was significantly delayed in both flanks compared with naïve B4B8 and B4B8TK cells. Growth of B4B8TK tumors in the ipsilateral flank was retarded following GCV treatment, but in contrast to B4B8FL and B4B8FL/TK cells, no distant bystander effect in the contralateral flank was observed. Immunohistochemistry showed lymphocytic infiltrates in both flanks of the B4B8FL and B4B8FL/TK groups. The data indicate that in these cells, local secretion of Flt3-L is sufficient to evoke a distant bystander effect but that expression of HSVTK, even after GCV administration, is not. Furthermore, the combination of local Flt3-L and HSVTK production, together with GCV administration, does not enhance the distant bystander effect produced by Flt3-L alone.

Principles and techniques of en bloc vertebrectomy for bone tumors of the thoracolumbar spine: an overview.

Oncological principles for en bloc resection of bone tumors were initially developed for tumors of the long bone by orthopedic surgical oncologists. Recently, spine surgeons have adopted these principles for the treatment of vertebral column tumors. The goal of en bloc resection is to establish a surgical margin that can be designated marginal or wide. In this article, the principles of surgical oncology for bone tumors of the spine are briefly reviewed and the different surgical approaches used to remove these tumors in an en bloc fashion are described in detail.